‘Until we get equality in education, we won't have an equal society’ - Justice Sonia Sotomayor.
What is the purpose of this blog? The authors will use two professions in health and social care to raise awareness of issues that impact an inclusive curriculum. We plan to explore with readers using two lived experiences that demonstrate some of the challenges that need to be aired and openly discussed in health and social care education.
The authors have a nursing and social work background, two professions that are at the forefront of care delivery in a growing diverse population in the United Kingdom. Health and social care should reflect the needs of all service users, most especially the vulnerable and marginalised.
The first scenario presents the care of a young 21-year-old man Evan Nathan Smith who had sickle cell disorder that died in hospital because he was not given oxygen therapy due to the lack of understanding of his condition (Thomas, 2021).
Sickle cell disorders are genetically inherited blood conditions found in people of African, Caribbean, Middle Eastern and the Mediterranean affecting approximately 12,500-15,000 people in England (National Institute for Health and Care Excellence, 2021).
This case is particularly pertinent to the discussion of this blog because it demonstrates how the lack of awareness and understanding of the basic health implications of this condition was missed by nurses and doctors. A coroner ruled that had the medical staff recognised the symptoms and provided timely treatment this young man would not have died. What can we learn from this tragedy as healthcare educators of the future workforce?
The most important learning from the above case is to ensure that nursing curricular is inclusive of all ethnic populations. Therefore, observations of vital signs should show for example, how a patient who needs oxygen therapy presents irrespective of their skin colour.
This means that as educators we need to scrutinise what we teach and how this reflects the needs of the entire population of service users. The understanding of health and social care does not reflect current demographics of the UK and lacks awareness of the implications of diversity and complexities that the different populations bring.
Recently a young medical student Malone Mukwende, recognised the lack of text to help doctors and nurses see how certain disease present in Black patients. The book titled ‘Mind the Gap’ stands as a guide to visualise the appearances and related pathology of diseases in non-White people. Without oversimplifying this very basic understanding of disease presentation, it is even more imperative to understand the psychosocial aspects which go beyond physical presentations.
The need for holistic approach to care transcends physical presentations as stated earlier and goes beyond hospital or clinic settings into the community. The second author, Akudo Amadiegwu, recalls her experience as a master’s social work student in her first year when working with a South Asian boy with craniopharyngioma. He was referred to the social work department for emotional support after experiencing bullying, but his case was initially closed because he did not attend appointments.
Craniopharyngiomas are rare brain tumours that develop near the hypothalamus and pituitary gland situated to the base of the brain and can affect vision, as it did in this young person. Other symptoms he suffered included headaches, problems with learning and thinking, word processing and word finding challenges. However, as Wilson and Powell (2001) argue an awareness of a child’s familial and cultural background is a key determinant of effective practitioner/child communication. This can be challenging as Teater (2014) finds, that less verbal service users may find it difficult to articulate or express other factors that may contribute to their impairment which was the case in this young boy’s situation.
My role as the social worker therefore was to establish other contributory factors (Milner and O’Byrne 2009) by being culturally aware (Bhugra and Gupta 2011). This meant understanding his social location as a migrant, there were issues around access to specialist support and lack of awareness of services (Hatton and Shah 2002: Laird 2008; NHS 2022). There were also issues regarding social isolation which as Bhugra and Gupta (2011) found, there are barriers which may impede the social interaction of migrant children such as language, bullying as in this case, the attitudes of the host communities which results in difficulty in integrating into the new society. This particularly affects children’s ability to form attachments thereby negatively affecting their sense of belonging and self-worth.
As a social worker, I supported the young boy by using a whole family approach and parent partnership was key as familial relationships are important in these communities with parents having a high commitment to education, social and economic status. Heer et al (2012) recommend a joined-up approach which includes collaborative working with parents and this was adopted including sharing information with the parent without any preconceived ideas. As Hatton and Shah (2002) states, South Asian parents appreciate information given to them face to face and in a clear manner as will be the case for other parents.
The authors acknowledge that the process of unlearning and incorporating other worldviews can be challenging as practitioners may find it difficult to navigate the inherent complexities.
Therefore, a decolonised curriculum in health and social care should incorporate all aspects of care and not limiting this to a ‘tick-box exercise’ which is tokenistic and does nothing to embrace the ethos of inclusivity. Awareness of other cultures and communities’ cultural context of care is highly imperative in practice. Bhugra & Gupta (2010) insist that good clinical practice must consider issues related to diversity and this is not just limited to the UK context. Our professions are international; therefore, we must expose our students to this broader context and provide the tools to practice internationally.
The Beveridge Report (1942) which gave rise to Social Insurance and the National Health Service (NHS) had the aims to slay the five giants of squalor, ignorance, want, idleness and disease, to meet the needs of every member of society irrespective of social status ‘from cradle to grave’. Therefore, the NHS and social care as we know it were founded upon the principles of social justice – equal access and opportunities and it is on this premise, that our argument proceeds.
The movement for decolonisation is burgeoning from the outback of Australia, through South Africa and Europe to the Americas, from the calls for indigenisation from the aborigines in Australia to the resistance movement characterised by #rhodesmustfall where protest action by South African students lead to a wider call to decolonise the curriculum. It is a call to incorporate other knowledges into the western curriculum with its ideologies that is largely taught in health and social care. The march of civilisation is migratory (people move from one place to another). With the international appeal of our professions, it is imperative that students have the right foundation to inform their practice.
Social work and nursing degree programmes have the most diverse applicants in comparison to other major undergraduate disciplines (Universities and Colleges Admission Services (UCAS), 2019). However, the higher representation of this demographic is not translated in literature and in practice placement as Rajan-Rankin (2015) found, black students feel ‘othered’ or ‘invisible’.
Situating this in critical and radical social work, with the central aim of drawing attention to inequality, Rajan-Rankin advocates for anti-racist social work education ‘abreast with rapid changes in a super-diverse, multicultural society’, with the inclusion of ‘blackness, migration and diaspora studies’ in the core content of the curriculum and a ‘broader complement of race theory and diversity studies’ included in continued professional development (CPD) for social work practitioners. This being achievable by a decolonised approach to social work education.
Nursing curriculum like social work needs an integrated approach that does not just treat diseases that affect Black and Asian communities as an ‘add on’ rather than incorporating the needs of these communities into all aspects of the curriculum. Therefore, understanding a condition such as sickle cell disease should not be taught in isolation to skills needed to identify observations that would alert a nurse of patient deterioration i.e., oxygen saturation levels.
The recent report by the NHS Race and Health Observatory (2021) identified how the conventional oximetry devises can misrepresent the oxygen saturation (levels) of patients with darker skin pigments as was demonstrated during the recent COVID-19 pandemic when Black patients died due to poor interpretation of their oxygen levels.
A criticism of this report is that it recommends further research without providing practical realistic interventions needed to supplement these readings in the interim. Therefore, as an educator of nurses, I would teach students to use multiple measures and observations to compare with these readings. For example, listen to the patient, look at their body language, in some instances there is a change in skin colour (may present as a yellowish tinge or dull complexion). However, the important thing to know is what is the norm for that patient and variation from that norm could be an indicator of deterioration.
Our approach therefore must be to have a curricular informed by ‘wider social, political, economic, cultural and environmental ideas’ (Cook 2020) that respectfully incorporates the wisdom gained by indigenous knowledge and other worldviews. We must therefore consciously interrogate the foundations or roots of our preconceived notions and be willing to inculcate in our teaching other knowledges.
This goes beyond race superiority as Saini (2019) argues that race is a social construct. ‘Race, shaped by power, has acquired a power of its own’. This then reinforces the argument that we are born different and therefore some people are more superior in intellect and character. Saini (2019) argues against this approach as she says’ ‘this is how power works, it takes, it claims, and keeps’ (p.14). Conversely, it disempowers; this goes against the principles of social justice and human rights, foundations on which our own professions are built. Knowledge is such a powerful tool; it shapes our thoughts and our worldview. And it becomes the truth. What we teach and how we teach it matters.
Most importantly, our takeaway message:
School of Health and Social Care, University of Essex
Akudo Amadiegwu is a Lecturer in the School of Health and Social Care, and a social worker registered with Social Work England. Her research focuses on patients with brain injuries and how social workers can support them and their families.
School of Health and Social Care, University of Essex
Professor Winifred Eboh is a Registered Nurse and Midwife, and the Director of Staff Development and Wellbeing, and Postgraduate Research Director in the School of Health and Social Care. Her research interests cover genetics related to the haemoglobinopathies, specifically sickle cell and thalassaemia, and the impact of racism and health inequalities on marginalised communities when accessing healthcare and social care.